Provider Demographics
NPI:1891711941
Name:DOMENGEAUX, JOAN A (PT)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:A
Last Name:DOMENGEAUX
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8109A SALERNO ST
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-2422
Mailing Address - Country:US
Mailing Address - Phone:760-386-2846
Mailing Address - Fax:
Practice Address - Street 1:BLDG 166 4TH STREET
Practice Address - Street 2:
Practice Address - City:FT. IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-380-6862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04173225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist